Does a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? A Retrospective Case-control Study in a Czech Tertiary University Hospital

Does a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? 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A Retrospective Case-control Study in a Czech Tertiary University Hospital Zuzana Kremenova, Jan Svancara, Petra Kralova, Martin Moravec, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-625443/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: More than 50% of patients worldwide die in hospitals. It is well known that end-of-life hospital care is costly. Our aims were to test whether the support of the palliative team can reduce end-of-life costs and to study the mechanisms of cost reduction. Methods: This was a one-centre descriptive retrospective case-control study. Big data from registries of routine visits were used for case-control matching. We included the expenses billed to the insurance company and added separately charged drugs and materials. We compared the groups over the duration of the terminal hospitalization, ICU days (ICU=intensive care unit), IV antibiotic use (IV=intravenous), MRI/CT scans (MRI/CR=magnetic resonance imaging/computed tomography), oncologic treatment in the last month of life, and documentation of the dying phase. We searched for all in-hospital cases who died in the university hospital in Prague with the support of the hospital palliative team from January 2019 to April 2020 and matched them with similar controls. The controls were matched according to age, sex, Charlson comorbidity index and diagnosis recorded on the death certificate. Results: We identified 213 dyads. The average daily costs were three times lower in the palliative group (4,392.4 CZK per day=171.3 EUR) than in the non-palliative group (13,992.8 CZK per day=545.8 EUR), and the difference was caused by the shorter time spent in the ICU (16% vs 33% of hospital days). This was probably due to better documentation of the dying phase in the medical records. Conclusions: To date, there are sparse hospital data available on the economic aspects of end-of-life care. We showed that the integration of the palliative care team in the dying phase can be cost saving. The evidence that hospital palliative care can save a substantial amount of money can be used to support the integration of palliative care in hospitals in middle- and low-income countries. A multicentre study with the same design is planned in the future to increase the strength of the results. Health Economics & Outcomes Research palliative care hospital cost savings end of life medical records Figures Figure 1 Figure 2 Background Palliative care is developing rapidly in Czech hospitals. The first hospital palliative care consult teams were established in 2016 and play a leading role in implementing palliative care in hospital settings. The palliative care team of the Faculty Hospital Kralovske Vinohrady in Prague is one such team. The opportunities available to maintain and prolong life in modern medicine give rise to medical and ethical dilemmas involving patients reaching the end of life. Difficult questions arise regarding whether specific treatments and diagnostic procedures are appropriate and beneficial to these patients. Intensified therapeutic and diagnostic procedures are often performed during terminal hospitalization despite their burden on the patients, the limited clinical value and the substantial healthcare costs. 1 Sometimes further treatment is withheld, and an existing treatment is discontinued at the end of life to prevent futile healthcare. 2 However, healthcare provided to the dying person can also be very intense, and some studies demonstrate that costs are the highest in the dying phase. 3 Integration of palliative care in hospitals is associated with not only clinical benefits but also economic impact. 4 Total direct hospital costs can be reduced in cancer and noncancer patients when the patient is supported by a palliative care team. 5 , 6 Maintaining patients’ autonomy at the end of life is not only a matter of making choices and medical decisions but also an active preparation for their death and allows them to state their preferences for the end of their life. 7 Documentation of the patient’s preferences and stating the code status early are associated with a less aggressive end of life. 8 Advanced care documentation can also encourage end-of-life discussions and preparations. 9 Family members and those close to the patient should be involved in end-of-life planning and supported by the staff. Methods Aims To determine whether integration of the hospital palliative care team at the end of life can prevent the use of burdensome diagnostic and therapeutic procedures. To prove that if the palliative care team is involved, it gives clearer context to the end of life, as the dying phase is documented. To prove that integration of hospital palliative care teams at the end of life can prevent transitions to intensive care and lower healthcare costs. Design We used a case-control observational retrospective study design. The differences in the end-of-life between the two groups of patients with (palliative care group) and without (nonpalliative care group) the support of the hospital palliative care team were compared. We retrospectively analysed and documented data from paper and electronic medical records of the terminal hospitalization. Setting The Faculty Hospital Kralovske Vinohrady is a tertiary university hospital in Prague, with 1,200 beds serving a catchment area of approximately 300,000 inhabitants. Patients in the catchment area are the oldest of all Prague inhabitants. The hospital palliative care team was established in 2016, and with 748 new patients per year (in 2020), it is the most efficient and one of the most advanced teams in the Czech Republic. This has led to the implementation and development of specialist hospital palliative care in the country. Nearly one-third of the patients indicated to the team die during their terminal hospitalization. There were approximately 1,100 deaths in the hospital, with 15–19% of dying patients supported by the palliative care team. Participants All in-patients who died between January 2019 and April 2020 were eligible for the study. Cases were supported by the hospital palliative care team during the dying phase. They were matched with similar controls from all deceased patients not supported by the team. Routine big data from the National Death Registry and the National Registry of Hospital Activity were used for matching. Controls had similar diagnoses on the death certificate, sex, age group, and Charlson comorbidity index. Power analysis was performed to calculate the sample size large enough to demonstrate the presence of an economically relevant financial difference between the two groups. Data collection Data were collected from paper and electronic medical records. Three researchers, all physicians (2 internists and 1 oncologist), analysed the records of the deceased patients. They inserted the variables into a prepared template. When the semiqualitative data were analysed, content analysis of the written data was carried out according to an approved mechanism about which a consensus was reached by all researchers and the project manager. Economic analysis was performed by counting all hospital costs of health care procedures billed to the insurance company, including medications and materials. Variables Estimation of the total daily costs of a terminal hospitalization and the determination of their difference between the control group and cases were the primary outcomes. The secondary outcomes were the length of the terminal hospitalization, days in the intensive care unit, the use of IV antibiotics, chemotherapy and radiotherapy in the last month, and the number of costly diagnostic procedures (CT/MRI scans). Another secondary outcome was the difference between the groups in documenting the fact that the patient was dying. Content analysis of the words referencing the dying phase was approved before data collection by consensus of all three researchers and the project leader. Time spent in the care of the palliative team was a potential confounder; therefore, it was included in the dataset. Demographic differences were decreased by case-control matching using age, diagnosis, comorbidities, and sex. The results could have been biased by the data collection methodology and analysis of medical records. For this reason, regular monthly meetings of the researchers and the project manager were scheduled to assure clarification of potential uncertainties and to approve a unified model of data collection. All data were inserted into an Excel chart made for this purpose. Reporting The STROBE checklist for case-control studies was used to report the study results. The study protocol was registered with the Technology Agency of the Czech Republic programme ÉTA 3 grant called Dying Matters [TL03000709]. Data analysis and statistical methods The geometric mean and logarithmic transformation of hospital costs were used for power analysis and sample size calculation because of the asymmetric distribution of data. A total of 195 patients in each group were needed to prove the cost difference of 10,000.00 CZK between the groups with a 0.05 level of significance and a power of 0.8. We used PS Power and Sample Size Calculations (version 3.0). Standard descriptive statistics were adopted for the description of the data. Numerical variables were described using the mean, standard deviation and 95% confidence interval. Categorical variables were described using absolute and relative frequencies of categories (percentages). The statistical significance of differences between the clinical and control groups was tested by Fisher’s exact test for categorical variables and by the Mann-Whitney U test for numerical data. The results were considered statistically significant at the level of alpha < 0.05 in all applied analyses. Analyses were performed using IBM SPSS Statistics 25.0.0 (IBM Corporation, 2017). Results Participants A total of 213 patients who received the support of the palliative care team and 213 controls who died without the support of the palliative care team were included in the study (102 women and 111 men). Eighty-one percent had a main oncologic diagnosis reported on their death certificate, and 19% had a nononcologic diagnosis. All participants died during the study period, from January 2019 to April 2020. They were grouped according to the Charlson comorbidity index into 3 groups (0–1, 2–4, 5 or more) and matched; therefore, the comorbidity figures in the two groups were the same. Table 1 Participant characteristics and length of hospitalization Palliative team intervention Yes (n = 213) No (n = 213) p Sex female 47.9% (n = 102) 47.9% (n = 102) 1.000 male 52.1% (n = 111) 52.1% (n = 111) Length of hospitalization < 3 days 9.9% (n = 21) 34.3% (n = 73) 1 month 5.6% (n = 12) 7.0% (n = 15) Oncologic diagnosis Yes 173 (81.2%) 174 (81.7%) 1.000 No 40 (18.8%) 39 (18.3%) Hospitalization We proved that there was a significant difference between the groups in the length of terminal hospitalization. Integration of the palliative care team resulted in significantly shorter terminal hospitalizations (mean = 14.3 days in the palliative care group vs 18.4 in the non-palliative care group, p ≤ 0.001). (Table 2 ) Patients with palliative care interventions spent significantly less time in the intensive care unit (16% of the hospital days in the palliative care group vs 33% in the nonpalliative care group, p ≤ 0.001). (Table 2 ) Context of care was clearer in the palliative care group because 62.4% of the deceased were reported as dying in the medical records, compared to only 30.5% in the nonpalliative care group (p ≤ 0.001). (Table 3 ) Table 2 Differences in costs and costly diagnostic and therapeutic procedures Palliative team intervention Yes (n = 213) No (n = 213) Mean Standard deviation 95% CI Mean Standard deviation 95% CI p Daily costs (CZK) 4,392.4 4,419.9 3,795.4-4,989.4 13,322.8 32,992.8 8,866.6–17,779.0 < 0.001 Total costs (CZK) 64,754.1 124,046.3 47,999.7–81,508.5 85,617.2 168,254.4 62,891.8–108,342.6 0.558 Length of hospitalization 14.27 31.43 10.03–18.52 18.37 77.52 7.90-28.84 < 0.001 Daily doses of IV antibiotics 1.91 1.88 1.65–2.16 1.78 2.17 1.49–2.08 0.204 Rate of ICU days (ICU days/total days of terminal hospitalization) 0.16 0.31 0.12–0.20 0.33 0.44 0.27–0.39 < 0.001 CT or MRI scans (number of scans/maximal number of scans in the group) 0.46 0.85 0.35–0.58 0.60 0.96 0.47–0.73 0.117 Table 3 Differences in oncologic treatment and documentation of the dying phase Palliative team intervention p Yes (n = 213) No (n = 213) Chemotherapy in the last month Yes 3.3% (n = 7) 6.6% (n = 14) 0.178 No 96.7% (n = 206) 93.4% (n = 199) Radiotherapy in the last month Yes 2.8% (n = 6) 4.2% (n = 9) 0.601 No 97.2% (n = 207) 95.8% (n = 204) Dying documented in the medical records Yes 62.4% (n = 133) 30.5% (n = 65) < 0.001 Cost differences We calculated all costs of a terminal hospitalization, which was the primary outcome of the study. There was no significant difference between groups in the total costs, but there were more outliers with extremely expensive hospitalizations in the nonpalliative group (Fig. 1 ). The average daily costs were three times lower in the palliative care group (4,392.4 CZK = 171.3 EUR per day) than in the nonpalliative care group (13,992.8 CZK = 545.8 EUR per day, p ≤ 0.001), and there was a significant difference in the daily hospital costs exceeding 10,000.0 CZK (p ≤ 0.001) (Table 2 , Fig. 2 ). Chemotherapy and radiotherapy in the last month of life were used similarly, without a significant difference between the cases and the controls (chemotherapy 3.3% in the palliative care group vs 6.6% in the non-palliative care group, p = 0.178, radiotherapy 2.8% in the palliative care group vs 4.2% in the non-palliative care group, p = 0.601) (Table 3 ). We also did not demonstrate any significant difference in IV antibiotic use (1.91 doses/day in the palliative care group vs 1.78 doses/day in the nonpalliative care group, p = 0.201) (Table 2 ). The usage of diagnostic MRI and CT scans was also similar, and the average number of scans during terminal hospitalization was 0.46 in the palliative care group vs 0.6 in the nonpalliative care group per hospitalization. (p = 0.117) (Table 2 ). Discussion Main findings This study provides clear evidence that integration of the hospital palliative care team during the dying phase can save substantial healthcare costs. We proved that daily costs are three times less expensive in patients supported by a palliative care team. The cost savings are mainly due to the prevention of transfer to the ICU; patients with palliative team support have significantly fewer days spent in the ICU and shorter terminal hospitalizations compared to their matched controls. Moreover, palliative care intervention makes the context of care clear. Twice as many patients in the palliative care group had the dying phase documented in their medical records compared to the nonpalliative care group. Strengths and limitations To our knowledge, this is the first study to examine cost savings related to hospital palliative care interventions not only in the Czech Republic but also in the Central European region. The large sample size (n = 213) increases the strength of the results. The number of patients was higher than that recommended by power analysis, so a significant difference in primary outcome was reached. Patients of different age groups, cancer types, and noncancer diagnoses were included, and they were properly matched using big national data from registries and propensity scores; therefore, the biases were reduced to a minimum. There is no recommended methodology available for healthcare cost calculations in the dying phase, so we developed our own that accounted for all the costs of procedures billed to the insurance company, medications, materials, and diagnostic procedures. The methodology will be published in detail on the website of the Czech Society of Palliative Medicine and can be used for free by Czech hospitals. There are also several limitations of the study. The external validity of the study results is limited, as it is a one-centre study and is not international. The retrospective study design limits the richness of data, and especially in the dying phase documentation, it does not mean that when death was not documented in the records, it was not discussed with the patients and staff. The semi-qualitative assessment of the dying phase in medical records and the words used to describe the dying process could have been biased by the researchers. We organized monthly meetings of all three researchers and the project leader to clarify discrepancies and to approve a unified method of data collection and content analysis. Implications for practice The evidence that hospital palliative care can save a substantial amount of money can help when advocating and negotiating with stakeholders, as hospital palliative care teams are not yet financed by the healthcare system in the Czech Republic and many other countries. It can also be used to support the integration of palliative care in hospitals in middle- and low-income countries. Transfer of patients to the ICU in the dying phase is burdensome and does not provide any benefit. Integration of palliative care in hospital settings can prevent these transfers and allow for a peaceful death. Future research Efforts are ongoing to repeat our study design and to include more hospitals to improve the generalizability and strength of the study. Economic evaluation studies in palliative care are sparse, and more research on the cost-effectiveness of palliative care interventions is still needed. Conclusion Our findings suggest that hospital palliative care teams can help to provide cost-effective end-of-life care. The cost savings are mainly due to the prevention of transfer to the ICU; patients with palliative team support have significantly fewer days spent in the ICU and shorter terminal hospitalizations. Moreover, palliative care intervention clarifies the context of care. The dying phase is more often documented in medical records when patients are supported by the palliative care team. Abbreviations ICU=intensive care unit IV=intravenous MRI/CR=magnetic resonance imaging/computed tomography Declarations Ethical considerations and consent to participate This research project was performed in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Faculty Hospital Kralovske Vinohrady in Prague (number EK-VP/62/0/2019). All methods were performed in accordance with approved study protocol and ethical guidelines. Informed consent to participate was obtained from next of kin of deceased patient. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files (Dataset_dying_matters.xlms). Competing interests The authors declare that they have no competing interests. Funding The authors disclosed receipt of the following financial support for the research, authorship, and publication of this article: This project was funded by the Technology Agency of the Czech Republic programme ÉTA3 grant called Dying Matters [TL03000709]. Authors’ contributions ZK contributed to the design of the study, led it, secured its funding, and drafted the article. Critical revisions were made by JS, MKB, MM, and HK; JS contributed to case-control matching, statistics, and data analysis; MKB, MM, and KH collected the data from the records; and PK performed the economic evaluation. Acknowledgements The authors would like to thank the Czech Society of Palliative Medicine, particularly Ondrej Slama and Martin Loucka, for their valuable comments and recommendations on the study design and their guarantee of the implementation of the study results in practice. The authors would also like to thank Ivan Rychlik and Martin Havrda, who are the heads of the internal department, for their general support of the research team. ORCID ID Zuzana Kremenova https://orcid.org/0000-0002-5375-6747 Jan Svancara https://orcid.org/0000-0003-1692-3339 Petra Kralova https://orcid.org/0000-0003-2427-1262 Martin Moravec https://orcid.org/0000-0001-6357-3576 Katerina Hanouskova https://orcid.org/0000-0002-9252-5239 Mayara Knizek-Bonatto https://orcid.org/0000-0002-9659-6560 References Jahn-Kuch D, Domke A, Bitsche S, et al. End-of-life decision making by Austrian physicians - a cross-sectional study. BMC Palliat Care 2020; 19: 4. 2020/01/07 . DOI: 10.1186/s12904-019-0509-3. Dasch B and Zahn PK. Prevalence of therapeutic and diagnostic procedures in the last 14 days of life in hospital patients: a single-center observational study from Germany. Ann Palliat Med 2021 2021/04/10 . DOI: 10.21037/apm-20-2435. May P, Normand C, Cassel JB, et al. Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis. JAMA Intern Med 2018; 178: 820–829. 2018/05/02 . DOI: 10.1001/jamainternmed.2018.0750. May P, Garrido MM, Cassel JB, et al. Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect. J Clin Oncol 2015; 33: 2745–2752. 2015/06/10 . DOI: 10.1200/jco.2014.60.2334. May P, Normand C, Del Fabbro E, et al. Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses. MDM Policy Pract 2019; 4: 2381468319866451. 2019/09/20. DOI: 10.1177/2381468319866451 . Yadav S, Heller IW, Schaefer N, et al. The health care cost of palliative care for cancer patients: a systematic review. Support Care Cancer 2020; 28: 4561–4573. 2020/05/23. DOI: 10.1007/s00520-020-05512-y . Houska A and Loučka M. Patients' Autonomy at the End of Life: A Critical Review. J Pain Symptom Manage 2019; 57: 835–845. 2019/01/07. DOI: 10.1016/j.jpainsymman.2018.12.339 . Caissie A, Kevork N, Hannon B, et al. Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward. Support Care Cancer 2014; 22: 375–381. 2013/10/01 . DOI: 10.1007/s00520-013-1983-4. Lewis E, Cardona-Morrell M, Ong KY, et al. Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review. Palliat Med 2016; 30: 807–824. 2016/03/10 . DOI: 10.1177/0269216316637239. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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CZK)","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-625443/v1/0fc0620353288df6759aa8ae.png"},{"id":14010938,"identity":"00852d0d-cc98-44c0-9045-17ec03a2c09f","added_by":"auto","created_at":"2021-09-27 12:29:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":285915,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-625443/v1/09cc62e0-064c-4928-8569-80124f7d2a0e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDoes a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? A Retrospective Case-control Study in a Czech Tertiary University Hospital\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003ePalliative care is developing rapidly in Czech hospitals. The first hospital palliative care consult teams were established in 2016 and play a leading role in implementing palliative care in hospital settings. The palliative care team of the Faculty Hospital Kralovske Vinohrady in Prague is one such team. The opportunities available to maintain and prolong life in modern medicine give rise to medical and ethical dilemmas involving patients reaching the end of life. Difficult questions arise regarding whether specific treatments and diagnostic procedures are appropriate and beneficial to these patients. Intensified therapeutic and diagnostic procedures are often performed during terminal hospitalization despite their burden on the patients, the limited clinical value and the substantial healthcare costs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Sometimes further treatment is withheld, and an existing treatment is discontinued at the end of life to prevent futile healthcare.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, healthcare provided to the dying person can also be very intense, and some studies demonstrate that costs are the highest in the dying phase.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Integration of palliative care in hospitals is associated with not only clinical benefits but also economic impact.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Total direct hospital costs can be reduced in cancer and noncancer patients when the patient is supported by a palliative care team.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Maintaining patients\u0026rsquo; autonomy at the end of life is not only a matter of making choices and medical decisions but also an active preparation for their death and allows them to state their preferences for the end of their life.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Documentation of the patient\u0026rsquo;s preferences and stating the code status early are associated with a less aggressive end of life.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Advanced care documentation can also encourage end-of-life discussions and preparations.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Family members and those close to the patient should be involved in end-of-life planning and supported by the staff.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eAims\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo determine whether integration of the hospital palliative care team at the end of life can prevent the use of burdensome diagnostic and therapeutic procedures.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo prove that if the palliative care team is involved, it gives clearer context to the end of life, as the dying phase is documented.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo prove that integration of hospital palliative care teams at the end of life can prevent transitions to intensive care and lower healthcare costs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDesign\u003c/p\u003e \u003cp\u003eWe used a case-control observational retrospective study design. The differences in the end-of-life between the two groups of patients with (palliative care group) and without (nonpalliative care group) the support of the hospital palliative care team were compared. We retrospectively analysed and documented data from paper and electronic medical records of the terminal hospitalization.\u003c/p\u003e \u003cp\u003eSetting\u003c/p\u003e \u003cp\u003eThe Faculty Hospital Kralovske Vinohrady is a tertiary university hospital in Prague, with 1,200 beds serving a catchment area of approximately 300,000 inhabitants. Patients in the catchment area are the oldest of all Prague inhabitants.\u003c/p\u003e \u003cp\u003eThe hospital palliative care team was established in 2016, and with 748 new patients per year (in 2020), it is the most efficient and one of the most advanced teams in the Czech Republic. This has led to the implementation and development of specialist hospital palliative care in the country. Nearly one-third of the patients indicated to the team die during their terminal hospitalization. There were approximately 1,100 deaths in the hospital, with 15\u0026ndash;19% of dying patients supported by the palliative care team.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eAll in-patients who died between January 2019 and April 2020 were eligible for the study. Cases were supported by the hospital palliative care team during the dying phase. They were matched with similar controls from all deceased patients not supported by the team. Routine big data from the National Death Registry and the National Registry of Hospital Activity were used for matching. Controls had similar diagnoses on the death certificate, sex, age group, and Charlson comorbidity index. Power analysis was performed to calculate the sample size large enough to demonstrate the presence of an economically relevant financial difference between the two groups.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eData were collected from paper and electronic medical records. Three researchers, all physicians (2 internists and 1 oncologist), analysed the records of the deceased patients. They inserted the variables into a prepared template. When the semiqualitative data were analysed, content analysis of the written data was carried out according to an approved mechanism about which a consensus was reached by all researchers and the project manager. Economic analysis was performed by counting all hospital costs of health care procedures billed to the insurance company, including medications and materials.\u003c/p\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003eEstimation of the total daily costs of a terminal hospitalization and the determination of their difference between the control group and cases were the primary outcomes.\u003c/p\u003e \u003cp\u003eThe secondary outcomes were the length of the terminal hospitalization, days in the intensive care unit, the use of IV antibiotics, chemotherapy and radiotherapy in the last month, and the number of costly diagnostic procedures (CT/MRI scans).\u003c/p\u003e \u003cp\u003eAnother secondary outcome was the difference between the groups in documenting the fact that the patient was dying. Content analysis of the words referencing the dying phase was approved before data collection by consensus of all three researchers and the project leader.\u003c/p\u003e \u003cp\u003eTime spent in the care of the palliative team was a potential confounder; therefore, it was included in the dataset. Demographic differences were decreased by case-control matching using age, diagnosis, comorbidities, and sex.\u003c/p\u003e \u003cp\u003eThe results could have been biased by the data collection methodology and analysis of medical records. For this reason, regular monthly meetings of the researchers and the project manager were scheduled to assure clarification of potential uncertainties and to approve a unified model of data collection. All data were inserted into an Excel chart made for this purpose.\u003c/p\u003e \u003cp\u003eReporting\u003c/p\u003e \u003cp\u003eThe STROBE checklist for case-control studies was used to report the study results. The study protocol was registered with the Technology Agency of the Czech Republic programme \u0026Eacute;TA 3 grant called Dying Matters [TL03000709].\u003c/p\u003e \u003cp\u003eData analysis and statistical methods\u003c/p\u003e \u003cp\u003eThe geometric mean and logarithmic transformation of hospital costs were used for power analysis and sample size calculation because of the asymmetric distribution of data. A total of 195 patients in each group were needed to prove the cost difference of 10,000.00 CZK between the groups with a 0.05 level of significance and a power of 0.8. We used PS Power and Sample Size Calculations (version 3.0).\u003c/p\u003e \u003cp\u003eStandard descriptive statistics were adopted for the description of the data. Numerical variables were described using the mean, standard deviation and 95% confidence interval. Categorical variables were described using absolute and relative frequencies of categories (percentages).\u003c/p\u003e \u003cp\u003eThe statistical significance of differences between the clinical and control groups was tested by Fisher\u0026rsquo;s exact test for categorical variables and by the Mann-Whitney U test for numerical data.\u003c/p\u003e \u003cp\u003eThe results were considered statistically significant at the level of alpha\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in all applied analyses. Analyses were performed using IBM SPSS Statistics 25.0.0 (IBM Corporation, 2017).\u003c/p\u003e "},{"header":"Results","content":" \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eA total of 213 patients who received the support of the palliative care team and 213 controls who died without the support of the palliative care team were included in the study (102 women and 111 men). Eighty-one percent had a main oncologic diagnosis reported on their death certificate, and 19% had a nononcologic diagnosis. All participants died during the study period, from January 2019 to April 2020. They were grouped according to the Charlson comorbidity index into 3 groups (0\u0026ndash;1, 2\u0026ndash;4, 5 or more) and matched; therefore, the comorbidity figures in the two groups were the same.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics and length of hospitalization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003ePalliative team intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.9% (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.9% (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.1% (n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.1% (n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLength of hospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9% (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.3% (n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 to 7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.8% (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.9% (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 to 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.7% (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.8% (n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6% (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0% (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOncologic diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e173 (81.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e174 (81.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (18.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHospitalization\u003c/p\u003e \u003cp\u003eWe proved that there was a significant difference between the groups in the length of terminal hospitalization. Integration of the palliative care team resulted in significantly shorter terminal hospitalizations (mean\u0026thinsp;=\u0026thinsp;14.3 days in the palliative care group vs 18.4 in the non-palliative care group, p\u0026thinsp;\u0026le;\u0026thinsp;0.001). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePatients with palliative care interventions spent significantly less time in the intensive care unit (16% of the hospital days in the palliative care group vs 33% in the nonpalliative care group, p\u0026thinsp;\u0026le;\u0026thinsp;0.001). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eContext of care was clearer in the palliative care group because 62.4% of the deceased were reported as dying in the medical records, compared to only 30.5% in the nonpalliative care group (p\u0026thinsp;\u0026le;\u0026thinsp;0.001). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences in costs and costly diagnostic and therapeutic procedures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003ePalliative team intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily costs (CZK)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,392.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,419.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,795.4-4,989.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13,322.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32,992.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8,866.6\u0026ndash;17,779.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal costs (CZK)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64,754.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124,046.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47,999.7\u0026ndash;81,508.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85,617.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e168,254.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62,891.8\u0026ndash;108,342.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.03\u0026ndash;18.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.90-28.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily doses of IV antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.65\u0026ndash;2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.49\u0026ndash;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRate of ICU days (ICU days/total days of terminal hospitalization)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12\u0026ndash;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.27\u0026ndash;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT or MRI scans (number of scans/maximal number of scans in the group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.47\u0026ndash;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences in oncologic treatment and documentation of the dying phase\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePalliative team intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChemotherapy in the last month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3% (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.6% (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.7% (n\u0026thinsp;=\u0026thinsp;206)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.4% (n\u0026thinsp;=\u0026thinsp;199)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRadiotherapy in the last month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8% (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2% (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.2% (n\u0026thinsp;=\u0026thinsp;207)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.8% (n\u0026thinsp;=\u0026thinsp;204)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDying documented in the medical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.4% (n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.5% (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCost differences\u003c/p\u003e \u003cp\u003eWe calculated all costs of a terminal hospitalization, which was the primary outcome of the study. There was no significant difference between groups in the total costs, but there were more outliers with extremely expensive hospitalizations in the nonpalliative group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average daily costs were three times lower in the palliative care group (4,392.4 CZK\u0026thinsp;=\u0026thinsp;171.3 EUR per day) than in the nonpalliative care group (13,992.8 CZK\u0026thinsp;=\u0026thinsp;545.8 EUR per day, p\u0026thinsp;\u0026le;\u0026thinsp;0.001), and there was a significant difference in the daily hospital costs exceeding 10,000.0 CZK (p\u0026thinsp;\u0026le;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChemotherapy and radiotherapy in the last month of life were used similarly, without a significant difference between the cases and the controls (chemotherapy 3.3% in the palliative care group vs 6.6% in the non-palliative care group, p\u0026thinsp;=\u0026thinsp;0.178, radiotherapy 2.8% in the palliative care group vs 4.2% in the non-palliative care group, p\u0026thinsp;=\u0026thinsp;0.601) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We also did not demonstrate any significant difference in IV antibiotic use (1.91 doses/day in the palliative care group vs 1.78 doses/day in the nonpalliative care group, p\u0026thinsp;=\u0026thinsp;0.201) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The usage of diagnostic MRI and CT scans was also similar, and the average number of scans during terminal hospitalization was 0.46 in the palliative care group vs 0.6 in the nonpalliative care group per hospitalization. (p\u0026thinsp;=\u0026thinsp;0.117) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eMain findings\u003c/p\u003e \u003cp\u003eThis study provides clear evidence that integration of the hospital palliative care team during the dying phase can save substantial healthcare costs. We proved that daily costs are three times less expensive in patients supported by a palliative care team. The cost savings are mainly due to the prevention of transfer to the ICU; patients with palliative team support have significantly fewer days spent in the ICU and shorter terminal hospitalizations compared to their matched controls. Moreover, palliative care intervention makes the context of care clear. Twice as many patients in the palliative care group had the dying phase documented in their medical records compared to the nonpalliative care group.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first study to examine cost savings related to hospital palliative care interventions not only in the Czech Republic but also in the Central European region. The large sample size (n\u0026thinsp;=\u0026thinsp;213) increases the strength of the results. The number of patients was higher than that recommended by power analysis, so a significant difference in primary outcome was reached. Patients of different age groups, cancer types, and noncancer diagnoses were included, and they were properly matched using big national data from registries and propensity scores; therefore, the biases were reduced to a minimum. There is no recommended methodology available for healthcare cost calculations in the dying phase, so we developed our own that accounted for all the costs of procedures billed to the insurance company, medications, materials, and diagnostic procedures. The methodology will be published in detail on the website of the Czech Society of Palliative Medicine and can be used for free by Czech hospitals.\u003c/p\u003e \u003cp\u003eThere are also several limitations of the study. The external validity of the study results is limited, as it is a one-centre study and is not international. The retrospective study design limits the richness of data, and especially in the dying phase documentation, it does not mean that when death was not documented in the records, it was not discussed with the patients and staff. The semi-qualitative assessment of the dying phase in medical records and the words used to describe the dying process could have been biased by the researchers. We organized monthly meetings of all three researchers and the project leader to clarify discrepancies and to approve a unified method of data collection and content analysis.\u003c/p\u003e \u003cp\u003eImplications for practice\u003c/p\u003e \u003cp\u003eThe evidence that hospital palliative care can save a substantial amount of money can help when advocating and negotiating with stakeholders, as hospital palliative care teams are not yet financed by the healthcare system in the Czech Republic and many other countries. It can also be used to support the integration of palliative care in hospitals in middle- and low-income countries. Transfer of patients to the ICU in the dying phase is burdensome and does not provide any benefit. Integration of palliative care in hospital settings can prevent these transfers and allow for a peaceful death.\u003c/p\u003e \u003cp\u003eFuture research\u003c/p\u003e \u003cp\u003eEfforts are ongoing to repeat our study design and to include more hospitals to improve the generalizability and strength of the study. Economic evaluation studies in palliative care are sparse, and more research on the cost-effectiveness of palliative care interventions is still needed.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eOur findings suggest that hospital palliative care teams can help to provide cost-effective end-of-life care. The cost savings are mainly due to the prevention of transfer to the ICU; patients with palliative team support have significantly fewer days spent in the ICU and shorter terminal hospitalizations. Moreover, palliative care intervention clarifies the context of care. The dying phase is more often documented in medical records when patients are supported by the palliative care team.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eICU=intensive care unit\u003c/p\u003e\n\u003cp\u003eIV=intravenous\u003c/p\u003e\n\u003cp\u003eMRI/CR=magnetic resonance imaging/computed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical considerations and consent to participate\u003c/p\u003e\n\u003cp\u003eThis research project was performed in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Faculty Hospital Kralovske Vinohrady in Prague (number EK-VP/62/0/2019). All methods were performed in accordance with approved study protocol and ethical guidelines. Informed consent to participate was obtained from next of kin of deceased patient.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files (Dataset_dying_matters.xlms).\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe authors disclosed receipt of the following financial support for the research, authorship, and publication of this article:\u003c/p\u003e\n\u003cp\u003eThis project was funded by the Technology Agency of the Czech Republic programme \u0026Eacute;TA3 grant called Dying Matters [TL03000709].\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eZK contributed to the design of the study, led it, secured its funding, and drafted the article. Critical revisions were made by JS, MKB, MM, and HK; JS contributed to case-control matching, statistics, and data analysis; MKB, MM, and KH collected the data from the records; and PK performed the economic evaluation.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Czech Society of Palliative Medicine, particularly Ondrej Slama and Martin Loucka, for their valuable comments and recommendations on the study design and their guarantee of the implementation of the study results in practice. The authors would also like to thank Ivan Rychlik and Martin Havrda, who are the heads of the internal department, for their general support of the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID ID\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZuzana Kremenova\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-5375-6747\"\u003ehttps://orcid.org/0000-0002-5375-6747\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eJan Svancara\u003ca href=\"https://orcid.org/0000-0003-1692-3339\"\u003e\u0026nbsp;\u003c/a\u003e\u003ca href=\"https://orcid.org/0000-0003-1692-3339\"\u003ehttps://orcid.org/0000-0003-1692-3339\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003ePetra Kralova\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0003-2427-1262\"\u003ehttps://orcid.org/0000-0003-2427-1262\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eMartin Moravec\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0001-6357-3576\"\u003ehttps://orcid.org/0000-0001-6357-3576\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eKaterina Hanouskova \u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-9252-5239\"\u003ehttps://orcid.org/0000-0002-9252-5239\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eMayara Knizek-Bonatto\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-9659-6560\"\u003ehttps://orcid.org/0000-0002-9659-6560\u003c/a\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJahn-Kuch D, Domke A, Bitsche S, et al. End-of-life decision making by Austrian physicians - a cross-sectional study. \u003cem\u003eBMC Palliat Care\u003c/em\u003e 2020; 19: 4. \u003cdiv class=\"ExternalRefDOI\"\u003e2020/01/07\u003c/div\u003e. DOI: 10.1186/s12904-019-0509-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDasch B and Zahn PK. Prevalence of therapeutic and diagnostic procedures in the last 14 days of life in hospital patients: a single-center observational study from Germany. \u003cem\u003eAnn Palliat Med\u003c/em\u003e 2021 \u003cdiv class=\"ExternalRefDOI\"\u003e2021/04/10\u003c/div\u003e. DOI: 10.21037/apm-20-2435.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay P, Normand C, Cassel JB, et al. Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis. \u003cem\u003eJAMA Intern Med\u003c/em\u003e 2018; 178: 820\u0026ndash;829. \u003cdiv class=\"ExternalRefDOI\"\u003e2018/05/02\u003c/div\u003e. DOI: 10.1001/jamainternmed.2018.0750.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay P, Garrido MM, Cassel JB, et al. Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect. \u003cem\u003eJ Clin Oncol\u003c/em\u003e 2015; 33: 2745\u0026ndash;2752. \u003cdiv class=\"ExternalRefDOI\"\u003e2015/06/10\u003c/div\u003e. DOI: 10.1200/jco.2014.60.2334.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay P, Normand C, Del Fabbro E, et al. Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses. \u003cem\u003eMDM Policy Pract\u003c/em\u003e 2019; 4: 2381468319866451. 2019/09/20. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2381468319866451\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadav S, Heller IW, Schaefer N, et al. The health care cost of palliative care for cancer patients: a systematic review. \u003cem\u003eSupport Care Cancer\u003c/em\u003e 2020; 28: 4561\u0026ndash;4573. 2020/05/23. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00520-020-05512-y\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHouska A and Loučka M. Patients' Autonomy at the End of Life: A Critical Review. \u003cem\u003eJ Pain Symptom Manage\u003c/em\u003e 2019; 57: 835\u0026ndash;845. 2019/01/07. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpainsymman.2018.12.339\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaissie A, Kevork N, Hannon B, et al. Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward. \u003cem\u003eSupport Care Cancer\u003c/em\u003e 2014; 22: 375\u0026ndash;381. \u003cdiv class=\"ExternalRefDOI\"\u003e2013/10/01\u003c/div\u003e. DOI: 10.1007/s00520-013-1983-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis E, Cardona-Morrell M, Ong KY, et al. Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review. \u003cem\u003ePalliat Med\u003c/em\u003e 2016; 30: 807\u0026ndash;824. \u003cdiv class=\"ExternalRefDOI\"\u003e2016/03/10\u003c/div\u003e. DOI: 10.1177/0269216316637239.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"palliative care, hospital, cost savings, end of life, medical records","lastPublishedDoi":"10.21203/rs.3.rs-625443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-625443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMore than 50% of patients worldwide die in hospitals. It is well known that end-of-life hospital care is costly.\u003c/p\u003e\u003cp\u003eOur aims were to test whether the support of the palliative team can reduce end-of-life costs and to study the mechanisms of cost reduction.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a one-centre descriptive retrospective case-control study. Big data from registries of routine visits were used for case-control matching. We included the expenses billed to the insurance company and added separately charged drugs and materials. We compared the groups over the duration of the terminal hospitalization, ICU days (ICU=intensive care unit), IV antibiotic use (IV=intravenous), MRI/CT scans (MRI/CR=magnetic resonance imaging/computed tomography), oncologic treatment in the last month of life, and documentation of the dying phase.\u003c/p\u003e\u003cp\u003eWe searched for all in-hospital cases who died in the university hospital in Prague with the support of the hospital palliative team from January 2019 to April 2020 and matched them with similar controls. The controls were matched according to age, sex, Charlson comorbidity index and diagnosis recorded on the death certificate.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe identified 213 dyads. The average daily costs were three times lower in the palliative group (4,392.4 CZK per day=171.3 EUR) than in the non-palliative group (13,992.8 CZK per day=545.8 EUR), and the difference was caused by the shorter time spent in the ICU (16% vs 33% of hospital days). This was probably due to better documentation of the dying phase in the medical records.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eTo date, there are sparse hospital data available on the economic aspects of end-of-life care. We showed that the integration of the palliative care team in the dying phase can be cost saving. The evidence that hospital palliative care can save a substantial amount of money can be used to support the integration of palliative care in hospitals in middle- and low-income countries. A multicentre study with the same design is planned in the future to increase the strength of the results.\u003c/p\u003e","manuscriptTitle":"Does a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? A Retrospective Case-control Study in a Czech Tertiary University Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-23 17:32:33","doi":"10.21203/rs.3.rs-625443/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9596315-d255-45e4-8a3f-68a6f009bf7a","owner":[],"postedDate":"June 23rd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":5233949,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2021-09-27T12:29:06+00:00","versionOfRecord":[],"versionCreatedAt":"2021-06-23 17:32:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-625443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-625443","identity":"rs-625443","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}